Multidisciplinary approach to deep-seated lesions requiring radiologically-guided fine-needle aspiration

Fine-needle aspiration (FNA) is a diagnostic modality that continues to improve in accuracy as training and experience accumulate. With increasing operator expertise and improved localization techniques, greater numbers of patients are able to benefit from FNAs performed on sites that are otherwise difficult or dangerous to reach by conventional surgery. We present a retrospective review of a 2-yr experience with radiologically-guided deep-seated FNA. In 115 cases involving transthoracic and transabdominal sites, we achieved the following overall figures: 91.9% sensitivity, 100% specificity, 93.9% diagnostic accuracy, 100% positive predictive value, and 80.6% negative predictive value. Our results are compared to those in other series. When properly applied, FNA of deep-seated lesions through image guidance is equivalent to tissue diagnosis obtained by laparotomy or surgical procedures. The benefits of FNA with or without core biopsy vs. scalpel biopsy are readily apparent when one considers the morbidity, cost, turnaround time, and trauma to the patient.

Apoptosis, bcl-2 expression, and proliferative activity in human endometrial stroma and endometrial granulated lymphocytes

Human endometrial leukocytes undergo regular cyclical changes during the menstrual cycle, with a striking increase in the phenotypically unusual population of CD56+ CD16- endometrial granulated lymphocytes (eGLs) in the late secretory phase and early pregnancy. The factors that regulate this increase in eGL numbers are unclear; their unusual morphology, however, has led to the suggestion that they undergo apoptosis at the end of the menstrual cycle. Apoptosis, bcl-2 expression, and proliferative activity were examined in the stroma of normal cycling, progesterone-treated, and early-pregnancy endometrium. The expression of bcl-2 and the Ki67 proliferation marker by highly purified (> 98% CD56+) eGLs from endometrium during the menstrual cycle and from first-trimester decidua was also studied. Apoptotic cells were rarely observed in the endometrial stroma of any of the samples examined. Stromal bcl-2 expression, however, increased from the proliferative to the premenstrual phase, and double immunohistochemical labeling demonstrated large numbers of bcl-2+ CD56+ eGLs. In contrast, Ki67 expression was high in the endometrial stroma during the proliferative phase, fell during the secretory phase, and rose again premenstrually, because of expression by eGLs. Isolated CD56+ eGLs also showed high bcl-2 and Ki67 expression at the end of the menstrual cycle. Unlike premenstrual endometrium, progesterone-treated endometrium and first-trimester decidua contained few proliferating cells, expressed high levels of bcl-2, and showed no evidence of apoptosis. Thus, eGLs do not undergo apoptosis in premenstrual endometrium, and their regulatory mechanisms remain to be clarified.

Plasmablastic morphology--an independent prognostic factor with clinical and laboratory correlates: Eastern Cooperative Oncology Group (ECOG) myeloma trial E9486 report by the ECOG Myeloma Laboratory Group

We studied the prognostic significance of plasmablastic (PB) multiple myeloma (MM) in Eastern Cooperative Oncology Group Phase III trial E9486. Two reviewers independently reviewed 453 cases. They agreed on 37 PB (8.2%) cases and 416 non-PB cases, achieving an 85% concordance (P < .0001). These PB cases had significantly lower hemoglobin and serum albumin levels, higher calcium and beta 2-microglobuin levels, and higher percentage BM plasma cells (PC) by immunofluorescence. They had higher bone marrow PC labeling indices, higher serum soluble interleukin-6 receptor (sIL-6R) levels, and a higher probability of ras mutations. Three treatment regimens were used: vincristine, bis-chloro-ethyl nitrosourea (BCNU) melphalan, cyclophosphamide, and prednisone (VBMCP) alone; VBMCP with added cyclophosphamide (HiCy); or recombinant interferon alpha 2 (rIFNalpha2). Although the numbers are low, patients with PB had a significantly lower response rate versus non-PB MM when treated with VBMCP (treated, 47.1% v nontreated, 66.5% [P = .015]). Patients with nonresponding PB had a significantly higher progression rate than non-PB cases (30.6% v 11.8% [P < .0001]), especially with VBMCP alone (35.3% v 15.8% [P = .002]), and with added HiCy (37.5% v 9.8% [P < .0001]), but not with added rIFNalpha2. Event-free and overall survival of PB MM was shorter (median years, 1.1 v 2.7 and 1.9 v 3.7, respectively [P < .0001 for both]). In multivariate analysis, PB classification was also highly prognostic. There is no survival difference between the patients who were classified as PB by both reviewers versus patients classified as PB by only one reviewer. We conclude that PB MM is a discrete entity associated with more aggressive disease and shortened survival. Tumor cell ras mutations and increased sIL-6R may contribute to a higher proliferation rate and reduced survival. There were significant improvements in response and progression with the addition of HiCy and rIFNalpha2 to VBMCP, but the numbers were small and improved survival could not be shown.

The safety and efficacy of switching timolol maleate 0.5% solution to timolol hemihydrate 0.5% solution given twice daily

This study was undertaken to evaluate the safety and efficacy of switching patients treated with timolol maleate to timolol hemihydrate. In patients with ocular hypertension or chronic open-angle glaucoma treated with beta-blockers for at least three months, we prescribed timolol maleate solution 0.5% given twice daily for one month. We then switched each patient to timolol hemihydrate solution 0.5% (Betimol, Ciba Vision Ophthalmics) given twice daily for three months. This study found over the first three months in 30 completed subjects, using a worse eye analysis, that the intraocular pressure changed from 18.3+/-2.1 mm Hg on timolol maleate to 18.8+/-2.3 mm Hg on timolol hemihydrate (P=0.10) 12 hours after dosing. There was no difference in the overall incidence of unsolicited anterior segment side effects between timolol maleate (4 cases) versus timolol hemihydrate (3 cases) (P=0.69). One patient exited the study because of pain and burning in both eyes while on timolol maleate. No patient was discontinued due to loss of intraocular pressure control after switching to timolol hemihydrate. It was concluded that switching from timolol maleate to timolol hemihydrate is safe and effective in maintaining control of the intraocular pressure.

Phase I clinical and pharmacokinetic trial of penclomedine using a novel, two-stage trial design for patients with advanced malignancy

PURPOSE

A novel phase I trial design was used to determine the maximum-tolerated dose (MTD) and pharmacokinetics for penclomedine when administered as an intravenous (i.v.) infusion over 1 hour daily for 5 days, repeated every 28 days. This study also tests the feasibility of a novel two-stage design for phase I trials.

PATIENTS AND METHODS

Twenty-eight patients with advanced malignancy who met standard eligibility criteria were treated with i.v. penclomedine. The initial daily dose was 50 mg/m2. Dose escalations were planned using a modified Fibonacci sequence. One patient was enrolled on each dose level during the first stage of this trial. In the second stage, patients were enrolled in cohorts of three, proceeding in an up-and-down manner based on toxicities observed. MTD was determined by logistic regression analysis. Pharmacokinetic assessment was performed during the first cycle of treatment.

RESULTS

Dose-limiting toxicities (DLT) observed during this trial were principally neurologic and were self-limited. Although hematologic toxicity was rare, the few patients with significant hematologic changes experienced late nadirs with prolonged time to recovery. The MTD was estimated as 381 mg/m2 (80% CI, 343 to 415 mg/m2). Although there was a long elimination half-life, accumulation of penclomedine over the 5 days of administration was negligible.

CONCLUSION

The novel trial design used in this study was safe and appeared effective in limiting the numbers of patients treated at lower-dose levels. Reversible neurotoxicity was dose-limiting. Although the estimated MTD was 381 mg/m2, any dose within the CI would be reasonable for phase II study.

Endometrial leucocytes: expression of steroid hormone receptors

BACKGROUND

Stromal leucocyte populations in human endometrium comprise T cells, macrophages, and phenotypically unusual endometrial granulated lymphocytes. Their proportions vary during the menstrual cycle and, in particular, endometrial granulated lymphocytes increase in number in the late secretory phase. The stimulus responsible for these cyclical changes is unknown but it is likely that the steroid hormones oestrogen and progesterone play a role.

AIMS

To define further the expression of steroid hormone receptors by leucocytes in non-pregnant and pregnant human endometrium.

METHODS

Frozen and paraffin wax embedded sections of endometrium from non-pregnant women and early pregnancy decidua were labelled using single and double immunohistochemical techniques with monoclonal antibodies directed against oestrogen and progesterone receptors and various leucocyte subpopulations.

RESULTS

Despite the prominence of CD56 positive endometrial granulated lymphocytes in late secretory phase endometrium and early pregnancy decidua, double immunohistochemical labelling showed no evidence of expression of either progesterone or oestrogen receptors by these cells or other endometrial leucocyte populations.

CONCLUSIONS

Rather than acting directly, steroid hormones are likely to influence endometrial leucocyte populations indirectly via products of endometrial stromal or epithelial cells that express steroid hormone receptors.

A randomized phase II trial of echinomycin, trimetrexate, and cisplatin plus etoposide in patients with metastatic nonsmall cell lung carcinoma: an Eastern Cooperative Oncology Group Study (E1587)

BACKGROUND

Patients with metastatic nonsmall cell lung carcinoma (NSCLC) usually have a poor prognosis. A chemotherapy regimen containing cisplatin is commonly used for symptom palliation. Echinomycin is a potent bifunctional intercalator of double-strand DNA; trimetrexate is a new derivative of methotrexate and is active against methotrexate-resistant tumor cells in vitro.

METHODS

The Eastern Cooperative Oncology Group conducted a randomized Phase II study. Eligible patients were assigned to receive echinomycin 1200 microg/m2 by intravenous (i.v.) infusion over 30-60 minutes once a week for 4 weeks, repeated every 6 weeks; trimetrexate 12 mg/m2 i.v. bolus on Days 1-5 every 3 weeks, or 8 mg/m2 i.v. bolus on Days 1-5 for patients who had prior radiation to greater than 30% of their bone marrow; or cisplatin 60 mg/m2 i.v. on Day 1 and etoposide 120 mg/m2 i.v. on Days 1-3 every 4 weeks. Patients were evaluated before each cycle for tumor response, toxicity, and quality-of-life measurements.

RESULTS

One hundred thirty-six patients were entered on the study, and 118 were evaluable for toxicity and response. The response rates were 16%, 5%, and 5% in patients treated with cisplatin and etoposide, echinomycin, and trimetrexate, respectively. There were no complete responses. The median survival was 37.9, 24.3, and 28.0 weeks for patients who received cisplatin and etoposide, echinomycin, and trimetrexate, respectively. Although cisplatin and etoposide appeared to give better therapeutic results, the response rate or survival did not reach statistical significance. This may have been due to inadequate sample size. Neither did quality-of-life measurement show any significant differences among treatments.

CONCLUSIONS

Echinomycin and trimetrexate had minimal antitumor activity in patients with metastatic NSCLC: Response rate and survival remained poor in all three treatment arms. Patients should be encouraged to participate in clinical trials so that more effective therapy can be identified.

Assessment of right ventricular function postretrograde cardioplegia by transesophageal echocardiography

The impact of continuous retrograde cardioplegia (RCP) on right ventricular (RV) function was evaluated prospectively with intraoperative transesophageal echocardiography (TEE) in 36 patients (23 males, 13 females) with a mean age of 60.4 years (ages 24-82). Operative procedures included 12 aortic valve replacements, 16 mitral valve repair/replacements, both with or without an associated cardiac operation, and 8 Ross procedures. Mean cardiopulmonary bypass (CPB) time was 123.3 minutes (66-280 minutes) with an average cross-clamp time of 88.9 minutes (43-199 minutes). The amount of cold blood RCP ranged from 3160-18,500 mL (mean = 7382.5), and the average pulmonary artery pressure was 35/18 mmHg. The coronary sinus was distally snared in 11 patients. TEE documented biventricular global dysfunction in two patients and post-CPB with preservation of the left ventricular function in all other patients. Localized akinesis of the RV apex and outflow tract were noted in three patients, and isolated worsening tricuspid insufficiency of moderate to severe intensity in six patients. Two of the six patients with worsening tricuspid insufficiency belonged to the snared coronary sinus group (11 patients). All of the documented RV dysfunctions were new and showed no correlation with the perfusion data.

IN CONCLUSION

(1) RV apex, RV outflow tract and tricuspid valve were particularly subject to important dysfunction post-RCP; (2) RCP did not protect RV adequately in 11 patients (31%); and (3) TEE is a convenient intraoperative technique in evaluating RV dysfunction.

Intraoperative intracameral carbachol in phacoemulsification and posterior chamber lens implantation

PURPOSE

To evaluate the use of intraoperative intracameral carbachol in association with phacoemulsification and posterior lens implantation.

METHODS

We prospectively randomly assigned 41 eyes (41 patients) to receive either placebo or a 50:50 dilution of carbachol 0.01% after intraocular lens insertion and phacoemulsification.

RESULTS

Twenty-one eyes of 21 patients treated with intracameral carbachol showed a statistically significant (P = .0373) reduction in intraocular pressure (15.9 mm Hg) at 6 hours postoperatively compared with 20 eyes of 20 patients who had received placebo (20.4 mm Hg). At day 1, the carbachol group measured 15.0 mm Hg vs 17.6 mm Hg for placebo (P = .0376), and a 1.5-line improvement in visual acuity in the carbachol vs the placebo group was noted (P = .0263), which was maintained on glare testing. On quality of life testing using a modified SF-36 test, carbachol-treated patients within the first postoperative week more often attempted to descent stairs in both bright (P = .007) and dim (P = .037) light than did patients treated with placebo. At month 2, no difference was observed between groups except that depth of focus was statistically greater in the carbachol group (P = .025). Safety was similar between the two groups in terms of ocular and systemic adverse events.

CONCLUSIONS

Patients treated with carbachol intracamerally after phacoemulsification and posterior chamber lens implantation demonstrate lower intraocular pressure within the first day postoperatively. These findings are associated with improved visual acuity and potentially greater ambulation in bright light within the first postoperative week.

Shortness of breath and jaundice

Images

Upper limb thrombosis associated with assisted conception treatment

Three cases of upper limb deep venous thrombosis occurring in association with assisted conception treatment are presented. The accepted argument that lower limb thrombosis occurring in cases of complicated or severe hyperstimulation syndrome represents the likeliest thrombo-embolic disorder in this situation is questioned.

Thromboembolic disease associated with ovarian stimulation and assisted conception techniques

Thromboembolic disease, as a complication of ovarian stimulation and assisted conception techniques, is generally considered to be a rare complication of ovarian hyperstimulation syndrome and, by implication, lower limb in origin. Sporadic cases of unusually sited thromboses, both venous and arterial, have been reported. This paper aims to draw attention to the relatively large number of such thromboses reported in the world literature compared with those cited in previous commentaries, and to emphasize how little is known about their pathogenesis. It is believed that this is an issue which requires to be addressed in order to understand the background pathology to such incidents and if possible to identify women at greatest risk from such potentially debilitating or fatal complications, such that appropriate prophylactic measures can be taken.

Topical 0.5% ketorolac vs 0.03% flurbiprofen for inhibition of miosis during cataract surgery

OBJECTIVE

To compare the effects of topical 0.5% ketorolac tromethamine ophthalmic solution (Acular, Allergen Pharmaceuticals, Irvine, Calif) with topical 0.03% flurbiprofen sodium ophthalmic solution (Ocufen, Allergen Pharmaceuticals) on the inhibition of surgically induced miosis during phacoemulsification cataract surgery.

DESIGN

One hundred eighteen patients were prospectively randomized to receive 0.5% topical ketorolac or 0.03% topical flurbiprofen at 3 preoperative intervals. The flurbiprofen-treated group served as the control group. The surgeon was masked as to patient selection. Horizontal pupillary diameter measurements were obtained at the start of surgery, just before phacoemulsification, before lens implantation, and after lens implantation.

RESULTS

Mean horizontal pupillary diameter measurements for both medications were similar at the start of surgery. However, a consistent trend of larger pupillary diameter was seen in all subsequent surgical intervals in the ketorolac-treated group. Changes from baseline measurements also indicated a more significant inhibition of miosis at all subsequent intervals, and a more stable mydriasis throughout the procedure in the ketorolac-treated group.

CONCLUSIONS

Topical ketorolac is an effective inhibitor of miosis during phacoemulsification cataract surgery, and provides a more stable mydriatic effect throughout the surgical procedure.

Surveillance for chronic fatigue syndrome--four U.S. cities, September 1989 through August 1993

PROBLEM/CONDITION

Although chronic fatigue syndrome (CFS) has been recognized as a cause of morbidity in the United States, the etiology of CFS is unknown. In addition, information is incomplete concerning the clinical spectrum and prevalence of CFS in the United States.

REPORTING PERIOD COVERED

This report summarizes CFS surveillance data collected in four U.S. cities from September 1989 through August 1993.

DESCRIPTION OF SYSTEM

A physician-based surveillance system for CFS was established in four U.S. metropolitan areas: Atlanta, Georgia; Wichita, Kansas; Grand Rapids, Michigan; and Reno, Nevada. The objectives of this surveillance system were to collect descriptive epidemiologic information from patients who had unexplained chronic fatigue, estimate the prevalence and incidence of CFS in defined populations, and describe the clinical course of CFS. Patients aged > or = 18 years who had had unexplained, debilitating fatigue or chronic unwellness for at least 6 months were referred by their physicians to a designated health professional(s) in their area. Those patients who participated in the surveillance system a) were interviewed by the health professional(s); b) completed a self-administered questionnaire that included their demographic information, medical history, and responses to the Beck Depression Inventory, the Diagnostic Interview Schedule, and the Sickness Impact Profile; c) submitted blood and urine samples for laboratory testing; and d) agreed to a review of their medical records. On the basis of this information, patients were assigned to one of four groups: those whose illnesses met the criteria of the 1988 CFS case definition (Group I); those whose fatigue or symptoms did not meet the criteria for CFS (Group II); those who had had an identifiable psychological disorder before onset of fatigue (Group III); and those who had evidence of other medical conditions that could have caused fatigue (Group IV). Patients assigned to Group III were further evaluated to determine the group to which they would have been assigned had psychological illness not been present, the epidemiologic characteristics of the illness and the frequency of symptoms among patients were evaluated, and the prevalence and incidence of CFS were estimated for each of the areas.

RESULTS

Of the 648 patients referred to the CFS surveillance system, 565 (87%) agreed to participate. Of these, 130 (23%) were assigned to Group I; 99 (18%), Group II; 235 (42%), Group III; and 101 (18%), Group IV. Of the 130 CFS patients, 125 (96%) were white and 111 (85%) were women. The mean age of CFS patients at the onset of illness was 30 years, and the mean duration of illness at the time of the interview was 6.7 years. Most (96%) CFS patients had completed high school, and 38% had graduated from college. The median annual household income/for CFS patients was $40,000. In the four cities, the age-, sex-, and race-adjusted prevalences of CFS for the 4-year surveillance period ranged from 4.0 to 8.7 per 100,000 population. The age-adjusted 4-year prevalences of CFS among white women ranged from 8.8 to 19.5 per 100,000 population.

INTERPRETATION

The results of this surveillance system were similar to those in previously published reports of CFS. Additional studies should be directed toward determining whether the data collected in this surveillance system were subject to selection bias (e.g., education and income levels might have influenced usage of the health-care system, and the populations of these four surveillance sites might not be representative of the U.S. population).

ACTIONS TAKEN

In February 1997, CDC began a large-scale, cross-sectional study at one surveillance site (Wichita) to describe more completely the magnitude and epidemiology of unexplained chronic fatigue and CFS.

Safety of beta-adrenergic blocker washout period in clinical trials

We prospectively evaluated the safety of the washout period from topical beta-adrenergic blockers prior to clinical drug trials. In 30 consecutive patients optic disc parameters (neural rim, optic disc, peripapillary halo and atrophy areas, and venous/arterial diameters) did not change following washout (p > 0.05). Likewise, the mean defect and pattern standard deviation (Humphrey 30-2) did not change following washout (p > 0.05). This study suggests, generally, the safety of the washout period prior to clinical drug trials.

Immune responses associated with chronic fatigue syndrome: a case-control study

An exploratory case-control study was conducted to assess whether the many reported differences in the immune function of chronic fatigue syndrome (CFS) patients are detectable in rigorously defined cases of CFS. Although many studies have reported differences between cases and controls in various measures of immune function, none of these differences were found in all studies. In this study, no differences were found in white blood cell numbers; immune complex, complement, or serum immunoglobulin levels; delayed type hypersensitivity and allergic responses; NK cell function; and proliferative responses to mitogens and antigens. Marginal differences were detected in cytokine responses and in cell surface markers in the total CFS population. However, when the patients were subgrouped by type of disease onset (gradual or sudden) or by how well they were feeling on the day of testing, more pronounced differences were seen.

Phase I clinical trial of melphalan and 41.8 degrees C whole-body hyperthermia in cancer patients

PURPOSE

To evaluate the biologic interactions and toxicities of melphalan (L-PAM) combined with 41.8 degrees C whole-body hyperthermia (WBH) for 60 minutes.

PATIENTS AND METHODS

Sixteen patients with refractory cancer were treated (May 1992 to May 1995) with WBH alone during week 1) thereafter patients were randomized to receive either L-PAM alone on week 2 and L-PAM plus WBH on week 5, or the reverse sequence. Patients who demonstrated clinical improvement received WBH plus L-PAM monthly. Dose levels of L-PAM were 10 mg/m2 (n = 3), 15 mg/m2 (n = 3), 17.5 mg/m2 (n = 6), and 20 mg/m2 (n = 4). L-PAM was administered at target temperature; WBH was administered with an Aquatherm radiant-heat device (patent pending; Cancer Research Institute, New York, NY).

RESULTS

Comparisons of mean WBC count and platelet nadirs for L-PAM alone and L-PAM plus WBH demonstrated that the addition of WBH resulted in nadir counts that were, on average, 25% lower. There were no instances of febrile neutropenia or bleeding. Toxicities allowed for escalation of L-PAM to 20 mg/m2; all four patients at this level experienced grade 4 myelosuppression. No significant myelosuppression was observed at 10 and 15 mg/m2. Grade 3 myelosuppression was observed in two of six patients at 17.5 mg/m2. Responses included complete remission (CR) of pancreatic cancer (10 mg/m2), partial remission (PR) of malignant melanoma in two patients (20 mg/m2), and transient clinical and/or serologic improvement in five patients. The pharmacokinetics of L-PAM were not altered by WBH. Observed cytokine induction by WBH is also discussed in detail.

CONCLUSION

We conclude that L-PAM with 41.8 degrees C WBH is well tolerated. Clinical results are consistent with preclinical predictions and provide a foundation for second-generation trials now in progress.

Total cholesterol and high-density lipoprotein levels as risk factors for increased intraocular pressure

PURPOSE

To determine whether high-density lipoprotein and total cholesterol levels were risk factors for increased intraocular pressure in patients with chronic open-angle glaucoma or ocular hypertension.

METHODS

We measured total cholesterol, high-density lipoprotein, and total cholesterol/high-density lipoprotein ratio in 25 patients with open-angle glaucoma or ocular hypertension who had taken no glaucoma medications for four weeks. We individually matched these patients to 25 control subjects who had no history of open-angle glaucoma or ocular hypertension, on the basis of age, race, gender, and history of vascular disease or diabetes mellitus.

RESULTS

We found no statistical difference in the high-density lipoprotein (P = .702) or total cholesterol (P = .177) levels or total cholesterol/high-density lipoprotein ratio between groups (P = .178, paired t test).

CONCLUSION

This study indicates that increased high-density lipoprotein and total cholesterol levels are not risk factors for increased intraocular pressure.

Outbreak of vertigo in Wyoming: possible role of an enterovirus infection

An epidemiologic investigation was conducted to characterize and evaluate the possibility of a viral aetiology of an outbreak of acute vertigo in Hot Springs Country, Wyoming, during autumn 1992. Case-finding identified Hot Springs County residents who sought medical attention for new onset vertigo during 1 August, 1992-31 January 1993. Thirty-five case-patients and 61 matched controls were interviewed and serum specimens were obtained during January 1993. Case-patients were more likely than controls to report symptoms (e.g. fatigue, sore throat, fever, diarrhoea) of antecedent acute illness. Case-patients did not have a significantly greater prevalence or mean titre of IgG antibodies to respiratory syncytial virus, parainfluenza viruses, Epstein-Barr virus, and cytomegalovirus than controls. Serologic evidence of recent enterovirus infection (IgM antibodies) was found for 74% of case-patients compared with 54% of controls (P < 0.05), suggesting a possible association between vertigo and enterovirus infection. Future studies are needed to define the role of enteroviruses in innerear diseases.

A more effective approach to in-hospital defibrillation

Survival rates from in-hospital cardiac arrests are low and have not improved since the 1960s. Increased emphasis on early defibrillation has significantly improved prehospital survival rates in recent years, but the organization of resuscitation efforts in hospitals has not changed. Nurses throughout the hospital should be trained and authorized to defibrillate on their own initiative, using defibrillators that are already close at hand. The basic procedure is not difficult, and an aggressive protocol using blind defibrillation could further simplify training and maximize survival. Working together, nurses can overcome psychologic and emotional barriers to these changes and improve their patients' odds of survival.

Risk of infection with hepatitis A, B or C, cytomegalovirus, varicella or measles among child care providers

BACKGROUND

Employment as a child care provider has been suggested as an indication for hepatitis A virus (HAV) immunization; however, whether this occupational group is at increased risk of HAV infection is not well-defined.

METHODS

We obtained sera samples for testing for antibodies to hepatitis A, B and C, cytomegalovirus, varicella and measles from a sample of child care providers in King County, WA, and administered a questionnaire to assess employment characteristics and other potential risk factors for infection. We also compared the anti-HAV seroprevalence among providers with that of subjects in the Third National Health and Nutrition Survey, representative of the US general population.

RESULTS

Thirteen percent (48 of 360) of providers were anti-HAV-positive (46% (22 of 47) of foreign born vs. 8% (26 of 313) of US-born (P < 0.001)). In multivariate analysis anti-HAV seropositivity was associated with foreign birth, age, income and Hispanic ethnicity but was not associated with characteristics of employment. Seroprevalence among US-born providers tended to be lower than that among Third National Health and Nutrition Survey subjects of similar age, sex, race and income. Sixty-two percent of providers were seropositive to cytomegalovirus, which was associated with nonwhite race, changing diapers > or = 3 days/week while at work and having a child in the household. Antibody prevalence was 1.4% to hepatitis B core antigen, 0.6% to hepatitis C, 94% to measles and 98% to varicella.

CONCLUSIONS

The anti-HAV prevalence among US-born providers was low, and seropositivity was not associated with employment characteristics, indicating that occupational exposure to HAV is uncommon under non-outbreak circumstances.

Human herpesvirus 6: infection and disease following autologous and allogeneic bone marrow transplantation

Human herpesvirus 6 activity (HHV-6) was studied in 15 allogeneic and 11 autologous marrow transplantation patients. After transplantation, HHV-6 was isolated from the peripheral blood mononuclear cells of 12 of 26 patients (6 allogeneic and 6 autologous). All isolates were variant B. Eleven of 26 and 12 of 19 patients showed salivary shedding of HHV-6 DNA before and after transplantation, respectively. The antibody titer increased in 7 of 26 patients. Thus, 23 of 26 patients showed evidence of active HHV-6 infection either by virus isolation, salivary shedding, or increases in antibody titers. The fraction of saliva specimens positive in 19 patients was negatively associated with their antibody titers (P= .005). The proportion of cultures positive increased after transplantation (P = .007). Sinusitis was associated with HHV-6 isolation in autologous recipients (P= .002). In allogeneic patients, active human cytomegalovirus infection was associated with HHV-6 isolation (P = .04). No association was observed between HHV-6 infection and GVHD, pneumonia, delay in engraftment, or marrow suppression. Of the 120 clinical events analyzed in 26 patients, HHV-6 was defined as a probable cause of 16 events in 9 patients based on the propinquity of HHV-6 activity and the clinical event plus the absence of other identified causes of the event.